Nokea
A client is experiencing an exacerbation of chronic lower back pain after working in the yard all weekend. The nurse should reinforce the primary importance of which nonpharmacologic intervention for acute muscle pain?
- A. Heating pad
- B. Positioning for comfort
- C. Rest from pain-aggravating activities
- D. Stretching exercises
Correct Answer: C
Rationale: For acute lower back pain, rest from aggravating activities is primary to prevent further strain. Heat and positioning are helpful but secondary, and stretching may worsen acute pain.
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While assessing the vital signs in children, the nurse should know that the apical heart rate is preferred until the radial pulse can be accurately assessed at about what age?
- A. 1 year of age
- B. 2 years of age
- C. 3 years of age
- D. 4 years of age
Correct Answer: B
Rationale: 2 years of age. A child should be at least 2 years of age to use the radial pulse to assess heart rate.
The nurse in the emergency department is caring for a newborn who has been vomiting. Which of the following findings may indicate that the newborn is experiencing a bowel obstruction?
- A. green colored vomit
- B. occasional vomiting since birth
- C. tiny streaks of blood in the vomit
- D. vomit coming through the nose
Correct Answer: A
Rationale: Green-colored vomit in a newborn suggests bile, indicating a possible bowel obstruction like malrotation or volvulus. Occasional vomiting , blood streaks , and nasal vomit are less specific.
A client comes to the emergency department for the second time with shortness of breath and substernal pressure that radiates to the jaw. The nurse understands that angina pectoris may be precipitated by which of these factors? Select all that apply.
- A. Amphetamine use
- B. Cigarette smoking
- C. Cold exposure
- D. Deep sleep
- E. Sexual intercourse
Correct Answer: A,B,C,E
Rationale: Angina can be triggered by amphetamines increasing cardiac demand, smoking causing vasoconstriction, cold exposure inducing vasospasm, and sexual intercourse raising heart rate. Deep sleep typically reduces demand.
When walking past a client's room, the nurse hears 1 unlicensed assistive personnel (UAP) talking to another UAP. Which statement requires follow-up intervention?
- A. If we work together we can get all of the client care completed.
- B. Since I am late for lunch, would you do this one client's glucose test?
- C. If we client seems confused, we need to watch another closely.
- D. I'll come back and make the bed after I go to the lab.
Correct Answer: B
Rationale: Only the RN and PN can delegate to UAPs. One UAP cannot delegate a task to another UAP. The RN or PN is legally accountable for the nursing care.
The nurse is reviewing the medical record of a 4-year-old client with failure to thrive. Which of the following risk factors likely contribute to the client's condition? Select all that apply.
- A. Child is the youngest of four children in the home
- B. One parent is incarcerated for spousal abuse
- C. One parent was diagnosed with anorexia nervosa prior to having children
- D. One parent works a full-time job outside the home
- E. Parents are concerned about not having enough money to buy food
Correct Answer: B,C,E
Rationale: FTT risk factors include parental incarceration causing family stress, a history of anorexia nervosa affecting feeding practices, and food insecurity . Being the youngest or a working parent are not direct risks.